Helicopter or Ambulance?

[sbp7993]

What would you do in this scenario? How would you transport? Could you consider a helicopter?

You have come upon an MVA patient. They rolled down an embakement, and fire has predicted a 45 minute extrication. A medic suggests that their might even be a spinal cord injury. At the moment, you have limited information. How would you proceed?

 

[busmonkey]

*Please keep in mind that this is technically a medics job and I am only an EMR and I haven't been trained in STARS Launch procedures yet*

Knowing my area is very rural and that there is no Trauma center within reasonable driving distance (up to a 45 minute drive followed by a 45 minute ferry followed by another 45 minute drive) I would immediately have Air placed on standby. I would wait until approaching the patient and doing full assessment prior to making the call for Air. If I felt that either the patient was in need of trauma care or if their immediate life was in danger (more than our local ER could take care of) I would call for Air right away.

 

[lightsandsirens5]

How far from the trauma center are you? What it the pt condition?

I'm thinking of a call we had. It was a diving accident with definate spinal injury. No feeling or movement from the nipple line down. No feeling or movement in arms. We called a bird based on MOI as soon as we began rolling. We had a 20 minute response, but transport to a lvl 2 would habe taken over an hour and a half. The bird arrived shortly after we did and took the pt.

Now for your scenario; if you are 10 minutes driving time, why call a bird? if you live in an area like I do, call the bird.

 

[busmonkey]

How far from the trauma center are you? What it the pt condition?

I'm thinking of a call we had. It was a diving accident with definate spinal injury. No feeling or movement from the nipple line down. No feeling or movement in arms. We called a bird based on MOI as soon as we began rolling. We had a 20 minute response, but transport to a lvl 2 would habe taken over an hour and a half. The bird arrived shortly after we did and took the pt.

Now for your scenario; if you are 10 minutes driving time, why call a bird? if you live in an area like I do, call the bird.

Defiantly agree with lights. It all depends on the variable travel time!

 

[usafmedic45]

Two things: 1. Don't start duplicate threads.
2. Never believe anything that comes out of the mouth of a representative of a HEMS company without independently verifying it through the scientific/medical literature. Most of the "criteria" HEMS operators put forth are based off of disproven "science", supposition and tradition more than benefit to the patient.

To quote my comments on your other thread (http://emtlife.com/showthread.php?t=18011)

If you are closer than an hour to a hospital, there is no real good reason to fly the patient. No unbiased study has shown significant benefit in the United States outside of extremely rural settings for scene response flights. The only thing guaranteed is profit for the helicopter companies and a steady supply of new names to go here: http://www.airmedicalmemorial.com/

 

[MonkeySquasher]

See the above post.


In my area, we are lucky enough to have not only one of the top Trauma centers in the Northeast, but also one of the best Stroke/Neuro centers in the Northeast as well, and they're within driving distance.

And companies up near the Lake, with at most a 1-hour drivetime to the Trauma Center, will call the helocopter with a 20+ minutes ETA, and then WAIT for it to land, package up the patient (who btw, rarely is dire enough to warrant said chopper), and then finally take off to fly the patient, at most, 30 miles (airborne, not surface roads). Making what could have been a 1:15-minute trip (load time, etc) take 1:20+ minutes.

But hey, it sure is cool, right? :deadhorse:

/endrant

 

[Commonsavage]

Our EMS serves a rural county, adjacent to a metro county, separated by 21 miles of mountain canyon. My personal determination is 30 minutes by ground will equal helivac to our Trauma 1. I do my best to assure that the chopper is 100ft from scene for rapid load and go. All credible sources show that rapid transport is the best determinate in positive outcomes for multisystem traumas, CVA, MI, etc. Virtually all stabilizing or life saving maneuvers can be accompliched in transit. I never wait for chopper. If they can be on the ground waiting for my intercept down the road, no closer than 30 minutes drive time out, I'll fly the patient. I don't allow my flight crews to dilly or dally.

 

[JakeEMTP]

Our EMS serves a rural county, adjacent to a metro county, separated by 21 miles of mountain canyon. My personal determination is 30 minutes by ground will equal helivac to our Trauma 1. I do my best to assure that the chopper is 100ft from scene for rapid load and go. All credible sources show that rapid transport is the best determinate in positive outcomes for multisystem traumas, CVA, MI, etc. Virtually all stabilizing or life saving maneuvers can be accompliched in transit. I never wait for chopper. If they can be on the ground waiting for my intercept down the road, no closer than 30 minutes drive time out, I'll fly the patient. I don't allow my flight crews to dilly or dally.

How do you determine a source is credible? If the study was sponsored by a for profit service the data will be in favor of what benefits them. Studies such as those are what have led to overuse and abuse of helicopters. Not every trauma patient will be rushed straight into the Operating Room like you see on TV and the better flight teams can do a very good job of stabilizing a patient just as the ED would do initially. While a rapid transport might benefit some patients, it should not be at the cost of more lives.

You on the ground should not be the one telling a pilot or flight crew how to fly their helicopter and patient. You should be giving them enough information prior to landing to allow them to make the safest decisions. They also have to consider the safety of the ground crews. The flight crew assumes care and will see that the patient is properly packaged for a safe flight for crew and patient. The last thing a helicopter crew needs is you loading a combative head trauma patient hot into their helicopter with no line and airway. Also, a trauma patient who is coding should not be loaded into the helicopter hot as dead people really should not be flown.

The pilot should also NEVER be rushed or forced to do something against his/her better judgment just because some ground crew member is yelling at him/her to not "dilly or dally" and that is for the safety of everyone. You refer to the flight crews as "yours" and if you are their employer you need to have more concern for their safety and responsibilities. A helicopter should be more than just a flying ambulance that goes real fast. It is this hysterical mindset that has led to poor decisions and more names on the air medical memorial page.

Do not overlook safety considerations in your haste to get the helicopter close to the scene and to have it fly real fast because the patient's care is out of your level of comfort. Let the flight crew and especially the pilot do their jobs to get the patient and themselves to the appropriate destination safely.

 

[Commonsavage]

How do you determine a source is credible? If the study was sponsored by a for profit service the data will be in favor of what benefits them. Studies such as those are what have led to overuse and abuse of helicopters. Not every trauma patient will be rushed straight into the Operating Room like you see on TV and the better flight teams can do a very good job of stabilizing a patient just as the ED would do initially. While a rapid transport might benefit some patients, it should not be at the cost of more lives.

You on the ground should not be the one telling a pilot or flight crew how to fly their helicopter and patient. You should be giving them enough information prior to landing to allow them to make the safest decisions. They also have to consider the safety of the ground crews. The flight crew assumes care and will see that the patient is properly packaged for a safe flight for crew and patient. The last thing a helicopter crew needs is you loading a combative head trauma patient hot into their helicopter with no line and airway. Also, a trauma patient who is coding should not be loaded into the helicopter hot as dead people really should not be flown.

The pilot should also NEVER be rushed or forced to do something against his/her better judgment just because some ground crew member is yelling at him/her to not "dilly or dally" and that is for the safety of everyone. You refer to the flight crews as "yours" and if you are their employer you need to have more concern for their safety and responsibilities. A helicopter should be more than just a flying ambulance that goes real fast. It is this hysterical mindset that has led to poor decisions and more names on the air medical memorial page.

Do not overlook safety considerations in your haste to get the helicopter close to the scene and to have it fly real fast because the patient's care is out of your level of comfort. Let the flight crew and especially the pilot do their jobs to get the patient and themselves to the appropriate destination safely.

Oy! A little defensive there. The vast majority of flight crews are awesome. I would NEVER presume to TELL a pilot or crew what to do. However, I have some volly services, and one municiple service, in my county that have a tendency to wait for chopper rather than close the distance. I have had a few instances where, in my best judgement, the flight crew dallied way too long on scene (30 minutes on an AMI. I should have cancelled them on scene and transported) and one instance where the pilot waited to inform us, and his crew, after packaging, that weather would not permit transport to primary trauma for 7yo w/ CHI GCS 9, and would be flying to secondary that would take longer than if I had driven the canyon. The flight crew was as outraged, as was I. Not to mention the family who arrived at hospital only to be told that their little girl was in another facility in another city.
And...who said anything about transporting the dead? Nobody flies without a sustainable rhythm and airway. Geez Loo-eez.
Not every crew is equal, ground or air

 

[JakeEMTP]

Oy! A little defensive there. The vast majority of flight crews are awesome. I would NEVER presume to TELL a pilot or crew what to do. However, I have some volly services, and one municiple service, in my county that have a tendency to wait for chopper rather than close the distance. I have had a few instances where, in my best judgement, the flight crew dallied way too long on scene (30 minutes on an AMI. I should have cancelled them on scene and transported)

How much stabilization was required? Did you just expect a scoop and run? Working a code in flight is not fun especially when it could be avoided by taking a few minutes to appropriately stabilize the patient rather than just running like an a bat out of hell or like you have no training to do anything for the patient.

What is with the BS about canceling them at scene? Is that just your way of showing them who's boss? You seriously need to stop playing these games and get over this "I'll teach you not to dally at my scene" attitude. Who is being treated? The patient or your ego?

What exactly is your level of training?

and one instance where the pilot waited to inform us, and his crew, after packaging, that weather would not permit transport to primary trauma for 7yo w/ CHI GCS 9, and would be flying to secondary that would take longer than if I had driven the canyon. The flight crew was as outraged, as was I. Not to mention the family who arrived at hospital only to be told that their little girl was in another facility in another city.

Would you rather they flew into the bad weather and crashed? Would it make you happy to just be able to say you made them fly and not dally regardless of the consequences? If the pilot says the flight plan changes because of weather, which can change quickly in some areas, it changes. If a flight crew gets angry because the pilot is considering their safety, they need to be fired. If you can not understand why a pilot would not want to chance flying in bad weather, you have no business being around these situations. Your anger or outrage which also may influence the flight crew has no place at the scene.

If the pilot told "us", does that mean you were still at scene and where was the family? Could you have not told the family they were changing the destination? If the crew had flown into bad weather and crashed the parents would probably have been notified their child was dead instead of being at another hospital.

 

[usafmedic45]

who said anything about transporting the dead? Nobody flies without a sustainable rhythm and airway

I would not say "nobody". There are a couple of times I've heard of some pretty questionable practices out of AirEvac Lifeteam, both of which involved flying people off scenes despite no vitals. Also, the kid (Jesse Arbogast, if I recall correctly) who was attacked by a shark in Florida in 2001 was flown to the hospital without vitals. The flight paramedic stated as much during a show that was aired during the Discovery Channel's Shark Week last year.

 

[usafmedic45]

and one instance where the pilot waited to inform us, and his crew, after packaging, that weather would not permit transport to primary trauma for 7yo w/ CHI GCS 9, and would be flying to secondary that would take longer than if I had driven the canyon. The flight crew was as outraged, as was I. Not to mention the family who arrived at hospital only to be told that their little girl was in another facility in another city.

Good for him. Better to live to fly another day than to die trying something really stupid. If the flight crew was that outraged, they need to have their attitudes adjusted. No patient is worth dying for. As for inconveniencing the family, **** them. Our job is to safely take care of the patient's ***, not to kiss those of the bystanders and family. They should be happy their daughter didn't die in a pointless helicopter crash along with those who tried to tend to her. If I find out who the pilot in question was, I'm buying him a beer.

 

[usafmedic45]

What is with the BS about canceling them at scene? Is that just your way of showing them who's boss? You seriously need to stop playing these games and get over this "I'll teach you not to dally at my scene" attitude. Who is being treated? The patient or your ego?

Keep in mind that a lot of EMS agencies have just as much capability as the helicopter crews (in some cases, more) so the ONLY reason to call for a helicopter is extremely long distance transfer. If they are honestly wasting time, I'm going to call them on it and as an aeromedical crew member, I would expect the same to be done to me.

It was allowed under our protocols to cancel the flight crew on scene if the patient's condition warranted it. The standard practice was to offer to let them ride along in the ground ambulance to the closest hospital. Of course, I can count on both hands the number of times (outside of the military) I called for a helicopter. Therefore, I only had to cancel them one time and that was due to marginal weather (a late summer afternoon with convective activity popping up nearby including between our location and the trauma center). I flat out refused to allow the patient to be loaded into the helicopter. The pilot ended up checking the weather and agreed with my judgment call. The flight nurse and paramedic rode along with us to the hospital.

 

[JakeEMTP]

Keep in mind that a lot of EMS agencies have just as much capability as the helicopter crews (in some cases, more) so the ONLY reason to call for a helicopter is extremely long distance transfer. If they are honestly wasting time, I'm going to call them on it and as an aeromedical crew member, I would expect the same to be done to me.

That part I understand. However, when it just comes down to just not liking the flight crew or not fully understanding why they are doing something before loading, then no an EMS ground crew member should not be playing those games. There are many aspects of care that some do not understand because they lack the training. The flight crew is assuming the responsibility of the patient and they are now providing the care.

Therefore, I only had to cancel them one time and that was due to marginal weather (a late summer afternoon with convective activity popping up nearby including between our location and the trauma center. I flat out refused to allow the patient to be loaded into the helicopter. The flight nurse and paramedic rode along with us to the hospital.

We also do not put a helicopter out of service if it can be avoided by using the crew as a ground team. There have been very rare exceptions where the only team available has been EMT-Bs.

If you saw the storm coming why didn't you tell the dispatch this or not call for the helicopter before it launched? A helicopter crew should not have to fly out in bad weather just to be extra hands for you unless there is a really valid reason for doing so such as specialized rescue or in the case of EMT-Bs only. However, for the case of EMT-Bs only, the transport time and time of arrival would have to be significant.

But again, safety is the primary concern. DO NOT encourage, insist or threaten a pilot into flying in a situation he/she does not feel is safe.

 

[usafmedic45]

If you saw the storm coming why didn't you tell the dispatch this or not call for the helicopter before it launched?

It was a prolonged extrication (guy walking in a corn field during harvest was struck by the combine and was entrapped from just below his waist in the head of the combine) and the convective activity started popping up while they were on scene. The reason we called for the helicopter was because they were flying with an emergency medicine resident (who was also a paramedic) on board. The weather when we called them out was pretty good- hot, humid but other than density altitude issues, not anything that would have kept me from flying. Once they were on scene things started to change very rapidly.

 

[Veneficus]

Just for general input and not directed at anyone.

I find it disturbing that any EMS member could somehow overrule or would even want to try to second guess a pilot except to cancel a flight for safety reasons. Part of the job of a pilot is to make sure everyone stays alive. Would you attempt to persuade a pilot to fly against his judgement on a commercial passenger aircraft?

We are talking about HEMS right? It is not the military. The rules are different.

Whether you are on a ground unit, aircraft, ship, or whatever, if you and/or the patient get killed then it was all for nothing. Rapid transport is only useful if it is safe. There are many things in this world that could end your life. (especially in the wilderness) If your (no matter who you are) passion gets in the way of sound judgement, it is time to move on to another profession. EMS is not about "risking ours to save yours" and all that other crap printed on t-shirts and glorified on tv and movies.

From the medical standpoint, I see many providers even now who because they do not see significant injuries or illness regularly enough are upset by it and their better judgement tends to succumb to the graphic nature. All patients need to be triaged objectively, an sometimes that means the "expectant" or dead category. (even if there is only one patient)

I think we have spouted "rapid transport," "get to a hospital," and the "surgical" nature of trauma care to the point where rational judgement is lost.

I understand that when a patient needs a surgeon, only a surgeon will do, but the amount of patients who actually need are rather uncommon.

By definition, all trauma patient are multisystem. If you pinch your arm hard enough to leave a bruise, you will have affected your skin, vascular system and musculoskeletal sytem, you don't hurry to the hospital screaming about needing a surgeon.

Especially if you do not see serious trauma very often, when you do see something "bad" take a time out for a minute, compose yourself, think slow, and act deliberately. If time is so critical to this patient they can't spare a couple of minutes, they are likely not going to make it out of the ICU anyway.

 

[MonkeySquasher]

Especially if you do not see serious trauma very often, when you do see something "bad" take a time out for a minute, compose yourself, think slow, and act deliberately. If time is so critical to this patient they can't spare a couple of minutes, they are likely not going to make it out of the ICU anyway.

I like this guy. He says what I'm thinking, so all I have to do is quote. haha


That's the kind of thought I'm trying to spark around here. Today, for the SECOND TIME IN A WEEK, the SAME local volly company arrived on scene, called for us as ALS. When my company got there, they called for a helicopter to land at our hall (10 miles away), to then intercept, transfer the patient, to fly another 20 miles to the trauma center. Estimated time from scene to trauma center? 45 minutes. Time from leaving scene until helicopter was airborne? 40 minutes... Add onto that the certainty of atleast 20 minutes flying/landing/offloading/elevator/moving into ER room.

/facepalm

 

[usafmedic45]

This is where a well-written report to their medical director can do a lot of good/damage.

 

[redcrossemt]

I want to make one point regarding the original post, and that is the fact that it's not *always* about transport time.

If we have a 45-minute extrication and a 10-minute ground transport time, it still might be in the patient's best interest to call a helicopter.

In my local area at least, our helicopter services carry blood, can do RSI, central access, chest tubes, etc. and our ground services can not.

If you can get a higher level of service (HEMS) to the critical patient before you could get them to a higher level (hospital), doesn't it make sense to do so?

 

[usafmedic45]

In my local area at least, our helicopter services carry blood, can do RSI, central access, chest tubes, etc. and our ground services can not.

OK, so you're willing to wait the 15-20 minutes (and that's a national average I heard quoted in a presentation at a conference recently; assuming you're on a scene that allows for the helicopter to easily find you, land quickly at the scene, the weather is cooperating, etc) for RSI? Why not get them to a closer, but perhaps less well equipped hospital that would be able to do all those things instead of waiting on scene? The helicopter can always come pick up the patient at that hospital for transfer to a tertiary care center, should they actually need to be transferred out. Remember EMS personnel do a piss poor job as a group identifying those patients who need to be flown versus those who do not. We massively overtriage people partly because of our adherence to tradition, partly due to the "cool" factor of calling for the helicopter and partly due to the disinformation campaigns of the HEMS industry and the accompanying willingness of our profession to sell the proverbial island for some beads ("Here's some pizza, pins and t-shirts. Be sure to call us for your next bad nosebleed OK?").

If you can get a higher level of service (HEMS) to the critical patient before you could get them to a higher level (hospital), doesn't it make sense to do so?

The problem is that it is an uncommon instance where that is the case, especially in SE Michigan (keep in mind I used to work in that neck of the woods) unless the EMS personnel are really just not moving fast enough. It may not be ideal to take them to the small community hospital, but if you're really talking rapid access to the basic level of advanced life support you are talking about then that is often the best choice.